Specifications Manual for Joint Commission National Quality Measures (v2023A1)
Posted: 10/17/2022

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Measure Information Form
Version 2023A1

Measure Information Form

Measure Set: Comprehensive Stroke (CSTK)

Set Measure ID: CSTK-05

Set Measure ID Performance Measure Name
CSTK-05a viewtopic Hemorrhagic Transformation for Patients Treated with Intra-Venous (IV) Alteplase Therapy Only
CSTK-05b viewtopic Hemorrhagic Transformation for Patients Treated with Intra-Arterial (IA) Alteplase Therapy or Mechanical Endovascular Reperfusion Therapy

Performance Measure Name: Hemorrhagic Transformation (Overall Rate)

Description:
CSTK-05 Ischemic stroke patients who develop a symptomatic intracranial hemorrhage (i.e., clinical deterioration ≥ 4 point increase on NIHSS and brain image finding of parenchymal hematoma, or subarachnoid hemorrhage, or intraventricular hemorrhage) within (≤) 36 hours after the onset of treatment with intra-venous (IV) or intra-arterial (IA) alteplase therapy, or mechanical endovascular reperfusion procedure (i.e., mechanical endovascular thrombectomy with a clot retrieval device).

CSTK-05a Ischemic stroke patients who develop a symptomatic intracranial hemorrhage (i.e., clinical deterioration ≥ 4 point increase on NIHSS and brain image finding of parenchymal hematoma, or subarachnoid hemorrhage, or intraventricular hemorrhage) within (≤) 36 hours after the onset of treatment with intra-venous (IV) alteplase therapy only.

CSTK-05b Ischemic stroke patients who develop a symptomatic intracranial hemorrhage (i.e., clinical deterioration ≥ 4 point increase on NIHSS and brain image finding of parenchymal hematoma, or subarachnoid hemorrhage, or intraventricular hemorrhage) within (≤) 36 hours after the onset of treatment with IA alteplase therapy or mechanical endovascular reperfusion therapy (i.e., mechanical endovascular thrombectomy with a clot retrieval device).

The CSTK-05 measure is reported as an overall rate which includes ischemic stroke patients who develop a symptomatic hemorrhage after reperfusion therapy. CSTK-05a and CSTK-05b are subsets of the overall rate, and stratified by the type of therapy.

Rationale: Intravenous (IV) alteplase therapy for acute ischemic stroke was approved by the US Food and Drug Administration in 1996, following findings from the National Institute of Neurological Disorders and Stroke (NINDS) trial which demonstrated favorable outcomes in 31% to 50% of patients treated with recombinant tissue plasminogen activator (r-tPA), as compared to 20% to 38% of patients treated with placebo. Intra-arterial (IA) alteplase therapy has since been used to improve recanalization and clinical outcomes for select patients nonresponsive to IV therapy. Intracranial hemorrhage is the major risk of thrombolytic therapy with similar rates reported for both IV and IA routes. The NINDS trial found that 6.4% of patients treated with IV alteplase experienced symptomatic bleeding. Findings from the Prolyse in Acute Cerebral Thromboembolism (PROACT II) study found the intracranial hemorrhage with neurological deterioration within 24 hours occurred in 10% of patients treated with IA recombinant prourokinase. In addition to these agents, other available thrombolytic drugs include: streptokinase, p-anisoylated lys-plasminogen-streptokinase activator, and urokinase.

Endovascular reperfusion therapy in acute ischemic stroke comprises a number of pharmacological and mechanical procedures. Mechanical endovascular thrombectomy is a treatment option for patients with large vessel occlusions in whom pharmacological thrombolysis is contraindicated or might be ineffective. For eligible patients, initiation of EVT (e.g., groin puncture) within 6 hours of stroke symptom onset using a stent retriever is preferred (Powers WJ, et. al., 2015). The use of mechanical thrombectomy devices other than stent retrievers as first-line devices for mechanical thrombectomy may be reasonable in some circumstances (Powers WJ, et. al., 2018). Mechanical endovascular thrombectomy devices are intended to improve tissue rescue and diminish reperfusion hemorrhage while broadening the population eligible for therapy. These devices may be used alone or in conjunction with chemical thrombolysis (i.e., IV or IA alteplase).

Type Of Measure: Outcome

Improvement Noted As: Decrease in the rate

Numerator Statement:
CSTK-05 Ischemic stroke patients who develop a symptomatic intracranial hemorrhage ≤ 36 hours after the onset of treatment with IV alteplase therapy, or IA alteplase therapy, or mechanical endovascular reperfusion therapy

CSTK-05a Ischemic stroke patients who develop a symptomatic intracranial hemorrhage ≤ 36 hours after the onset of treatment with IV alteplase therapy only (IVO)

CSTK-05b Ischemic stroke patients who develop a symptomatic intracranial hemorrhage ≤ 36 hours after the onset of treatment with IA alteplase therapy or mechanical endovascular reperfusion therapy

Included Populations: As above

Excluded Populations: None

Data Elements:

Data Elements By Measure
CSTK-05 CSTK-05a CSTK-05b
Arrival Date Arrival Date Arrival Date
Arrival Time Arrival Time Arrival Time
Highest NIHSS Score Documented Within 36 Hours Following IA Alteplase or MER Initiation Highest NIHSS Score Documented Within 36 Hours Following IV Alteplase Initiation Highest NIHSS Score Documented Within 36 Hours Following IA Alteplase or MER Initiation
Highest NIHSS Score Documented Within 36 Hours Following IV Alteplase Initiation IV Alteplase Initiation IA Route of Alteplase Administration
IA Route of Alteplase Administration IV Alteplase Initiation Date IA Alteplase or MER Initiation Date
IA Alteplase or MER Initiation Date IV Alteplase Initiation Time IA Alteplase or MER Initiation Time
IA Alteplase or MER Initiation Time NIHSS Score Documented Closest to IV Alteplase Initiation NIHSS Score Documented Closest to IA Alteplase or MER Initiation
IV Alteplase Initiation Positive Brain Image Positive Brain Image
IV Alteplase Initiation Date Positive Brain Date Positive Brain Image Date
IV Alteplase Initiation Time Positive Brain Image Time Positive Brain Image Time
NIHSS Score Documented Closest to IA Alteplase or MER Initiation    
NIHSS Score Documented Closest to IV Alteplase Initiation    
Positive Brain Image    
Positive Brain Image Date    
Positive Brain Image Time    

Denominator Statement: Ischemic stroke patients treated with IV alteplase therapy only (IVO) or IA alteplase therapy, or who undergo mechanical endovascular reperfusion therapy
Included Populations:
  • Discharges with ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A, Table 8.1 for ICD-10 codes,
    AND
  • Patients with documented thrombolytic (IV or IA alteplase) therapy (ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 8.1a for ICD-10 codes ),
    OR
  • Patients with documented Mechanical Endovascular Reperfusion Therapy (ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 8.1b for ICD-10 codes)

Excluded Populations:
  • Patients less than 18 years of age
  • Patients who have a Length of Stay > 120 days
  • Patients admitted for Elective Carotid Intervention
  • Patients transferred to this hospital following treatment with IV alteplase therapy or IA alteplase therapy or mechanical endovascular reperfusion therapy initiated prior to arrival at this hospital
  • Patients who hemorrhage prior to the onset of treatment with IV alteplase or IA thrombolytic alteplase or mechanical endovascular reperfusion therapy

Data Elements:

Risk Adjustment: Suspended. This section has been moved to the ORYX Risk Adjustment Guide. The guide is available to the public on the Joint Commission's website.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: Hospitals may wish to identify those patients who are at higher risk for hemorrhage following specific therapies, so that efforts can be directed toward improving care.

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

  • Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks E. Guidelines for the Early Management of Adults with Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007;38:1664-1666.
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  • Rubiera M, Ribo M, Pagola J, Coscojuela P, Rodrigues-Luna D, Maisterra O, Ibarra B, Piñeiro S, Meler P, Romero FJ, Alvarez-Sabin J, Molina CA. Bridging intravenous-intra-arterial rescue strategy increases recanalization and the likelihood of a good outcome in nonresponder intravenous tissue plasminogen activator-treated patients: a case-control study. Stroke. 2011 Apr;42(4):993-997.
  • Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. NEJM. 2015 Apr: 1-11.
  • Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, Clark W, Budzik R, Zaidat OO, for the SWIFT Trialists. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomized, parallel-group, non-inferiority trial. Lancet. 2012;380:1241-1249.
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  • Smith WS, et al. Mechanical thrombectomy for acute ischemic stroke. Stroke. 2008;39:1205-1212.
  • The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581-1587.
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Measure Algorithm:
CSTK-05_pg1.jpg v15 CSTK-05_pg2.jpg v9 CSTK-05_pg3.jpg v6 CSTK-05_pg4.jpg v8 CSTK-05_pg5.jpg v9 CSTK-05_pg6.jpg v10 CSTK-05_pg7.jpg v10 CSTK-05_pg8.jpg v8

Measure Information Form CSTK-05
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Specifications Manual for Joint Commission National Quality Measures (v2023A1)
Discharges 01-01-23 (1Q23) through 06-30-23 (2Q23)

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